The Doctor Is In… Your App: Online Providers Of Gender-Affirming Care

With the state of Florida officially ending Medicaid coverage of treatment for gender dysphoria this week, healthcare providers serving the transgender population find themselves increasingly on the defensive.

“There is social stigma,” said Dr. Jerrica Kirkley, who is board certified in family medicine and the co-founder and chief medical officer of Plume, a leading telehealth provider. Plume bills itself as a “company for trans people, by trans people.” Kirkley happens to be a trans woman.

“When you talk about really wanting to understand the patients’ experience and enhance that experience, there are many factors which you’re fighting against. There’s many things within the healthcare system, whether that has to do with payment access, health insurance and barriers that trans people are facing all the time. And so the social stigma is a component, but nothing new to that experience.”

This week’s salt in the wound is the decision by Florida’s Agency for Health Care Administration, which affects up to 9,000 of the state’s Medicaid enrollees who are transgender. Announced earlier this summer by Gov. Ron DeSantis, it’s a bandwagon move that is being challenged by a coalition of trans rights organizations, as Politico reported. Florida is the tenth state to ban Medicaid dollars from going to gender-affirming care, according to the Movement Advancement Project, a nonprofit research group. Treatments now banned include puberty blockers for trans and nonbinary youth, hormone therapies for both children and adults as well as surgical procedures. At least five more Republican-majority state legislatures are considering similar bans.

“As it has been with these attacks across the board, the cruelty is the point,” said Nikole Parker of Equality Florida. “Gender-affirming care is lifesaving care. That care is now being shut off by a state agency that has been corrupted, weaponized, and stacked with extremists by a governor desperate to fuel his own political ambitions.

The Human Rights Campaign also condemned the latest ban as an attack on the trans community and a “blatantly political move that ignores medical consensus and takes decisions about best care practices out of the hands of medical professionals and patients.”

“At a time where there still exist very large coverage deserts when it comes to access to gender-affirming care, in a time of anti-trans legislation, having a telehealth service that allows any individual in the United States to access care safely, regardless of where they live, I think is more important now than ever,” said Dr. Matthew Wetschler, Plume’s co-founder and CEO, in a joint Zoom call. He said he met Kirkley in their first year of medical school 15 years ago, and have been friends ever since.

Kirkley practiced in Colorado after completing her residency; Wetschler did his at Stanford and practiced in the San Francisco Bay area, but he’s also worked as a travel clinician and emergency physician, including at rural hospitals across the country.

Five years into her practice in Colorado, Kirkley joined forces with Wetschler to start Plume, dedicated to making gender-affirming care available in states where finding an experienced provider is next to impossible, and without the restrictions imposed by insurance companies.

“We actually started this with our own money,” said Wetschler, who happens to be a cisgender man. “We didn’t ask for permission, we had no support. It was literally money out of our pocket, $7,000 each, and a sign taped to the door in Colorado Springs. Three years later, we’re the largest trans provider that’s ever existed in the world.”

In 2019, Plume pioneered telehealth services specifically aimed at the transgender population in the U.S.. “We’re in 41 states currently across the country, coast to coast and serving about 11,000 active members and have taken care of about 17,000 total patients since we started a little under three years ago,” said Kirkley.

On Tuesday, the doctors announced their second round of funding through investment. Plume’s Series B funding round of $24 million is led by Transformation Capital with participation from General Catalyst and Townhall Ventures.

“Our firm has deep empathy and compassion for underserved communities—we believe the trans community deserves a better, more accessible care experience that is unfortunately not available to many in our healthcare system today,” said Jenna Ciotti, vice president at Transformation Capital, in a statement. “Plume is positioned to be a medical home for this important and growing community.”

“Bringing the $24 million is just a huge indicator of the momentum we have,” said Wetschler. “What that is going to enable is for us to be in all 50 states, moving to ensure that all trans individuals can use their insurance to pay for Plume.” Currently, their company does not accept insurance, nor do competing telehealth providers Folx and TrueU Clinic. Plume charges a $99 per month membership fee, which covers telehealth services, prescriptions and gender confirmation surgery letters, but not the cost of medication, which varies.

“One of the exciting things about this new round of fundraising is being able to accept health insurance, and multiple modes of health insurance,” noted Kirkley. “One thing we already do is a scholarship fund that provides a free year of care for trans folks and we’re partnering with Point of Pride on that.”

“We did not found this company to be a Denver-based clinic,” added Wetschler. “We founded this company to transform the landscape of healthcare access for the trans community.”

“With all the things that trans people are up against when it comes to accessing healthcare, that was the motivation to do this and wanting to knock down those barriers,” said Kirkley in our Zoom interview. The mission of Plume, she said, is “to transform healthcare for every trans life.”

“We do that through direct patient care, first and foremost,” said Kirkley. “But we also do that by being a leader in the field and forming guidelines for care and advocating for change at a legislative level. We never forget about that. And those are things that we’re working on all the time, even talking to congresspeople and public officials, to actually change what we’re seeing in that political landscape when it comes to trans advocacy.”

Regarding advocacy, it’s important to note: Gender dysphoria is not a mental disorder, according to the American Psychiatric Association, and is defined as the psychological distress that some transgender people experience when the sex they were presumed to be at birth does not align with their gender identity. The A.P.A. also cites studies that show gender-affirming care, including surgery, has long-term mental health benefits for trans individuals.

That may be news to Florida’s new deputy press secretary, formerly the spokesperson for the state department of health, who has received laudatory coverage in conservative media for refusing to use the term “gender-affirming care.” The spokesperson went so far as to troll a local television station that was seeking information, and boast about his master “class,” mocking the station on Twitter as “media activists,” just for using that phrase.

As Kirkley and Wetschler blogged back in May 2020: “Gender-affirming care is literally life-saving. Every major medical association in the United States, including the American Medical Association, the American Academy of Family Physicians, the American Psychiatric Association has recognized the necessity of providing transition-related care to improve the physical and mental health of transgender people.”

Florida is one of the 41 states served by Plume.

Read what the Association of American Medical Colleges says about gender-affirming care by clicking here.